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Author Manuscript
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Am J Prev Med. 2013 October ; 45(4): 501507. doi:10.1016/j.amepre.2013.05.012.

Current mHealth Technologies for Physical Activity Assessment

and Promotion
Gillian A. OReilly, BS and Donna Spruijt-Metz, PhD
Department of Preventive Medicine, Keck School of Medicine, University of Southern California,
Los Angeles, California

Abstract
ContextNovel mobile assessment and intervention capabilities are changing the face of
physical activity (PA) research. A comprehensive systematic review of how mobile technology
has been used for measuring PA and promoting PA behavior change is needed.
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Evidence acquisitionArticle collection was conducted using six databases from February to
June 2012 with search terms related to mobile technology and PA. Articles that described the use
of mobile technologies for PA assessment, sedentary behavior assessment, and/or interventions for
PA behavior change were included. Articles were screened for inclusion and study information
was extracted.

Evidence synthesisAnalyses were conducted from June to September 2012. Mobile phone
based journals and questionnaires, short message service (SMS) prompts, and on-body PA sensing
systems were the mobile technologies most utilized. Results indicate that mobile journals and
questionnaires are effective PA self-report measurement tools. Intervention studies that reported
successful promotion of PA behavior change employed SMS communication, mobile journaling,
or both SMS and mobile journaling.

ConclusionsmHealth technologies are increasingly being employed to assess and intervene

on PA in clinical, epidemiologic, and intervention research. The wide variations in technologies
used and outcomes measured limit comparability across studies, and hamper identification of the
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most promising technologies. Further, the pace of technologic advancement currently outstrips
that of scientific inquiry. New adaptive, sequential research designs that take advantage of
ongoing technology development are needed. At the same time, scientific norms must shift to
accept smart, adaptive, iterative, evidence-based assessment and intervention technologies that
will, by nature, improve during implementation.

Context
Increasing physical activity (PA) and decreasing sedentary behavior is protective for a
number of conditions, including obesity,1 diabetes,2 heart disease,3 depression,4 and some
cancers.5 However, recent studies show conclusively that most young people and adults in

2013 American Journal of Preventive Medicine

Address correspondence to: Gillian A. OReilly, BS, Department of Preventive Medicine, University of Southern California, 2001 N.
Soto Street, 3rd floor, Los Angeles CA 90033-9045., goreilly@usc.edu.
No financial disclosures were reported by the authors of this paper.
 OReilly and Spruijt-Metz Page 2

the U.S. do not meet the recommended PA guidelines.6 Further, extensive amounts of time
spent in sedentary behavior poses multiple threats to health.7 The success of traditional
interventions to improve PA and decrease sedentary behavior has been inconsistent,8 and
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most interventions do not scale.9

Mobile health (mHealth) has emerged as an important field for disease management, health
behavior assessment, and health behavior interventions. Mobile and connected technologies
have been adopted for these purposes because they offer novel approaches to measurement
and intervention methodologies. Moreover, mobile phones are used ubiquitously across age
groups and populations, suggesting that mobile technologies might offer cost-effective and
acceptable implementation tools for health behavior change and maintenance.

More than 85% of U.S. adults own mobile phones.10 Additionally, 77% of youth aged 12
17 years own mobile phones,11 an increase from 45% in 2004.12 The pervasive nature of
mobile technology lends mHealth tools the ability to fit seamlessly into peoples everyday
lives, providing avenues for novel ways to assess behavior in free-living settings. Coupled
with on-body sensing devices, mobile phones can collect and transmit objective, real-time
behavioral and biofeedback data.13,14 These rich data can provide insight into peoples
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behaviors in a context-specific manner. mHealth offers novel ways for interventionists,

researchers, and healthcare providers to communicate directly with individuals, opening up
the potential to provide constant reminders and immediate feedback in an adaptive, just-in-
time manner.1519

Further, mHealth assessments and interventions can implement features that are not only
acceptable but also enjoyable for individuals to use, including mobile applications, mobile
games, SMS messaging, and self-monitoring tools.20 These features enable mHealth to
move care and intervention programs toward implementation and adoption for long-term
behavior change maintenance, which is crucial in the face of the low levels of PA and high
levels of sedentary behavior in the U.S. populations, the related epidemic of obesity and
chronic conditions,2123 and the resulting economic burden on healthcare systems.24,25
mHealth technologies are poised to address the shortcomings of current assessment and
intervention techniques.

The current review focuses on studies that use mobile technology for activity assessment
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and activity promotion. Previous reviews have focused on computer- and Internet-based
interventions for PA2630; eHealth (e-mail, website, and SMS-based) interventions for
PA31,32 and/or dietary behavior change33; and active video games to increase PA in youth.34
Additionally, two reviews35,36 provide overviews of the use of mobile technology for
various health outcomes. One review to date has focused on mobile technology used
specifically for PA interventions, emphasizing efficacy of and user satisfaction with text
messagebased interventions.37 It focuses largely on interventions for weight management,
and includes seven articles that were published between January 2005 and August 2010. A
recent meta-analysis of 11 studies examined the efficacy of mobile devices to influence PA
behavior.38 No reviews to date have included mobile technologies for PA and sedentary
behavior assessment as well as interventions.

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Therefore, the aim of the current review was to provide a comprehensive assessment of
mobile technologies employed for both of these purposes. Further, this review provides an
update of studies published through June 2012 and includes 13 articles that have not been
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assessed in previous reviews of mobile technologies for PA interventions.3951 Considering

the fast pace with which technology develops and the fact that the mHealth field is quickly
expanding, an updated and expanded review is warranted. This systematic review focused
on addressing the following questions:

Which mobile technologies have been used for PA and sedentary behavior
detection and PA promotion?

Which mobile technologies are effective for PA and sedentary behavior

measurement and interventions?

Have mobile technologies been harnessed for their potential to provide real-time
feedback in adaptive behavioral interventions?

How feasible are mobile technologies for PA measurement and PA and sedentary
behavior interventions?

Evidence Acquisition
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Data Sources and Search Strategy

Articles were identified from searches in PubMed, Google Scholar, Web of Knowledge,
Ovid Healthstar, and IEEE Xplore databases, as well as from references cited in reviewed
articles and searches of relevant journals during February to June 2012. The following
search term was used: ((mobile phone OR cell phone OR text message OR SMS OR short
message service OR internet OR web OR e-mail OR electronic mail) AND (physical activity
OR active OR physical fitness OR exercise OR sedentary OR inactiv*)). The search terms
internet, web, e-mail, and electronic mail were included to account for the possibility of
studies using these technologies via mobile platforms to measure PA or implement
interventions for PA or sedentary behavior. Studies that were published in English as journal
articles or conference proceedings; described more than one participant; and described the
use of mobile phones for PA assessment, sedentary behavior assessment, and/or PA or
sedentary behavior interventions were considered for review.
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Inclusion/Exclusion Criteria
To be considered for full review, articles had to include a sample of youth or adults and
meet at least one of the following inclusion criteria:

Usability, feasibility, or evaluation studies describing mobile technology for PA or

sedentary behavior self-report

Usability, feasibility, evaluation, or intervention studies describing SMS messaging

for communication about PA or sedentary behavior

Usability, feasibility, or evaluation studies describing mobile technology for

objective PA or sedentary behavior detection

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Intervention studies describing mobile technology used to influence PA or

sedentary behavior
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Articles that described e-mail or website-based PA assessment or promotion that was not
implemented using mobile technology were not included because they did not describe how
mobile technologies could be utilized to implement the assessment or intervention. Although
users may not differentiate between mobile and web-based platforms, this is an important
distinction in the sphere of mHealth research. Web-based platforms are not necessarily
mobile-accessible to all users, so web-based content delivered via computers could have
different characteristics and elicit different user responses than web-based content delivered
via mobile devices. Additionally, articles that described only designs or engineering proofs,
but not the testing of designs with users, were not considered for review.

Identification of Relevant Studies

Articles were screened and questions about eligibility were discussed and resolved. Potential
articles were identified by first screening the title and then the abstract. Articles that were
considered potentially relevant from title and abstract screenings were screened in full for
final consideration.
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Summarizing Study Findings

Analyses were conducted JuneSeptember 2012. Information about study characteristics
(Appendix A, available online at www.ajpmonline.org) was extracted from the reviewed
articles. For PA behavior change outcomes, findings were considered significant if the p-
value was <0.05. For studies that did not include PA behavior change as a main outcome,
usability, feasibility, or other main findings were reported.

Study Quality Assessment

A critical assessment of the reviewed studies was conducted using the Effective Public
Health Practice Project (EPHPP) Quality Assessment Tool.52 This quality-assessment tool
has six subscales, including participant selection bias, study design, confounding, blinding,
data collection methods, and participant withdrawals and drop-outs. The subscales
pertaining to study design, confounding, and blinding are appropriate evaluation metrics for
intervention studies but not for non-intervention studies. Therefore, a modified version of
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the assessment tool excluding these subscales was used for non-intervention studies. Quality
scores were assigned to the studies (Appendix A, available online at www.ajpmonline.org).

Evidence Synthesis
Included/Excluded Articles
As of June 16, 2012, a total of 9509 articles were returned in the search results. After
reviewing the titles and abstracts of the search returns, 128 articles were considered for full
review. A final sample of 22 articles that met the inclusion/ exclusion criteria was included
in this review (Figure 1).

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Types of Mobile Technologies Utilized

Seventeen (77%) of the reviewed studies described mobile technologies for PA
promotion.39,41,42,4549,51,5360 Twelve of these used mobile technologies to implement PA
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interventions42,46,48,49,51,53,5560; others39,41,45,47,54 aimed to evaluate usability and

feasibility of PA-promoting mobile systems. The remaining five40,43,44,50,61 of the reviewed
studies tested mobile technologies for PA assessment.

Mobile journals or questionnaires, featured in 11 (50%) studies,40,42,43,46,47,4951,53,57,61

were the most commonly used mobile technologies. They were tested for both PA
measurement40,43,50,61 and PA behavior change through self-monitoring.42,46,47,49,51,53,57
Mobile journals were followed by SMS messaging, which was used in eight (36%)
studies.46,48,51,55,56,5860 SMS messaging was used in these studies to encourage PA
behavior change with automated messages46,51,56,5860 or personalized SMS messages.48,55
None of the reviewed studies used SMS for PA measurement. On-body activity-sensing
systems were described in five (23%) studies.39,41,44,45,54 (The number of studies in these
categories does not equal 22, as seven studies40,41,45,46,50,51,61 [32%] employed more than
one mobile technology.)
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Study Quality Assessment

Of the 22 studies reviewed, seven39,41,45,50,51,59,61 received weak quality ratings,
nine42,44,46,47,5355,57,60 received moderate quality ratings, and six40,43,48,49,56,58 received
strong quality ratings.

Of the 12 studies that used mobile technologies for PA interventions, two51,59 had weak
quality, six42,46,53,55,57,60 had moderate quality, and four48,49,56,58 had strong quality. Of the
five studies that aimed to evaluate usability and feasibility of PA-promoting mobile systems,
three39,41,45 received weak quality ratings and two47,54 received moderate quality ratings.
Two50,61 of the five studies that tested mobile technologies for PA assessment had weak
quality, whereas one had moderate quality44 and two had strong quality.40,43

Efficacy of Mobile Technologies for Physical Activity and Sedentary Behavior

Measurement
Six studies (27%), four40,43,46,50 that used mobile journals or questionnaires and two44,54
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that used mobile on-body sensing systems, assessed whether the mobile technologies they
used were suitable for PA and sedentary behavior measurement. Each of the
studies40,43,46,50 that evaluated mobile PA journals or questionnaires compared data
collected via these methods with data collected by validated PA measurement tools.
According to the results from these comparisons, self-report of PA and sedentary behavior
using mobile journals or questionnaires agreed with validated assessment tools.

Of the two studies44,54 that tested the efficacy of on-body sensing systems, one44 tested the
ability of the system to accurately detect real-time PA states, and one54 tested the ability of
the system to correctly infer activities in real time. The study44 that used a system to detect
PA states found that the system was 94% accurate in PA state detection compared to in-lab

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activity observations. The study54 that used a system to infer activities found that 61% of
activities recorded by participants were correctly inferred by the on-body sensing system.
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Efficacy of Mobile Technologies for Physical Activity and Sedentary Behavior Change
Of the 12 studies that used mobile technologies to influence PA behavior, nine (75%)
reported significant changes in PA42,46,53,5558,60 or sedentary behavior.49 These studies
employed SMS communication to promote PA,55,56,58,60 PA self-monitoring through
mobile journaling,42,49,53,57 or both SMS and journaling.46

Intervention tailoring using mobile technologies was featured in six of the

interventions.48,49,51,53,55,59 Tailoring strategies included displays of personal PA data and
progress toward PA goals,51,53 personally tailored SMS messages,48,55 and personalized
feedback to self-reported data.48,49,59 PA behavior change results from interventions that
used tailoring techniques were mixed. Three of these studies49,53,55 reported behavior
change outcomes. Two studies48,59 reported no changes in PA behaviors, and one51 did not
report statistical results. Although four studies39,41,45,54 described on-body mobile systems
that provided real-time feedback about PA behavior to users, which could be used to
implement personalized, adaptive interventions, none of the studies tested these mobile
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systems for efficacy of PA or sedentary behavior change.

Usability, Acceptability, and Feasibility Outcomes

The majority of the reviewed studies aimed to determine directions for future work through
evaluation outcomes related to usability, feasibility, or acceptability. One or more of these
outcomes was featured in 14 (64%) studies.3943,45,47,48,54,55,57,5961 Usability and
acceptability were assessed through participant interviews,39,48,54 questionnaires,41,57,61 and
tasks to test participant performance with the mobile technology.45 Responses for usability
were mixed, varying from 58% of participants agreeing that a mobile journal was easy to
use61 to all participants agreeing that an on-body sensing system was easy to use.39 The
studies that reported acceptability assessment outcomes revealed that on-body sensing
systems,54 mobile journals,43,47 and SMS messaging48,59 received positive acceptability
ratings from participants.

The results of feasibility assessments demonstrate that mobile platforms for journals and
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SMS messaging can be feasible for PA measurement and for implementation of PA

interventions. Two studies assessed the feasibility of mobile journals for PA
measurement.40,43 They found positive feasibility outcomes for use of mobile journals to
collect self-reported PA compared to energy expenditure estimated by doubly labeled water
and indirect calorimetry40 and PA measured by accelerometer.43 Additionally, one study42
that used a mobile journal and three studies48,55,60 that used SMS messaging determined
that these mobile technologies are feasible ways to deliver PA interventions. None of the
studies that employed on-body sensing systems assessed feasibility, so the literature does not
provide evidence of the feasibility of on-body systems for PA measurement or interventions.

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Discussion
A variety of mobile technologies have been used in mHealth PA assessment and promotion
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studies, including mobile journaling, SMS messaging, and on-body sensing systems.
Positive feasibility findings from studies that measured these outcomes indicate that mobile
journals and SMS messaging are viable measurement and intervention tools. However, on-
body sensing systems lack evidence for feasibility of PA measurement and intervention
delivery, so research is needed to determine how viable mobile on-body sensing systems are
for these purposes. The fact that usability of mobile technologies across modalities received
mixed results from study participants indicates that research is also necessary to determine
the features of mobile PA measurement and intervention technologies that are functional for
users.

The literature demonstrates that mobile technologies have largely been adopted as isolated
components and have not yet been integrated into comprehensive systems for use in
interventions. However, mHealth PA research has demonstrated some efficacy for
measuring PA and for influencing PA behavior and sedentary behavior change. Mobile
journals and questionnaires were found to be effective for PA measurement compared to
validated PA measurement tools.40,43,46,50 Of the six studies that tested these mobile
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technologies for PA measurement efficacy, five received strong40,43 or moderate44,46,54

quality ratings, which lends support to these findings. However, only two of the studies that
described mobile on-body sensing systems tested the systems for accuracy of PA and
sedentary behavior detection.44,54

The mixed results from these studies indicate that more research is needed to understand
how on-body sensing technologies can be used for accurate PA and sedentary behavior
measurement. Additionally, SMS,55,56,58,60 mobile journaling,42,49,53,57 or both SMS and
journaling46 were used to deliver several successful interventions. All of the studies that
reported significant PA or sedentary behavior changes received strong49,56,58 or
moderate42,46,53,55,57,60 quality ratings. The qualities and outcomes of these studies suggest
that SMS and mobile journaling can be used to implement effective PA interventions.

Although evidence62 suggests that tailoring may strengthen the efficacy of behavior change
interventions, few of the interventions used these technologies to deliver personalized
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interventions or real-time feedback. Moreover, behavior change outcomes from PA

interventions that used tailoring strategies were mixed. This may have been due in part to
the variable quality of studies that employed tailored interventions, as the studies that had
positive behavioral outcomes were strong49 or moderate,54,55 whereas those that did not had
weak quality ratings.50,59 Tailoring of mHealth PA interventions using real-time feedback
could provide context-specific, just-in-time support for behavior change. Evidence from the
education literature supports the benefits of immediate feedback; studies63,64 have
demonstrated that immediate feedback can enhance learning and improve behavioral
outcomes. Because mobile technologies have the capabilities for real-time feedback, this
tailoring strategy should be explored as a way to potentially improve mHealth PA
intervention efficacy.

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Gaps can be identified between current implementations and utilizing mHealth technologies
to their full potential for measuring activities in real time and providing personalized,
adaptive feedback to users. Mobile on-body sensing was the most seldom-used mobile
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technology. Despite the increasing capability of mobile on-body sensors to facilitate real-
time, personalized feedback to users in adaptive interventions, none of the studies in this
review used this mobile technology to change PA or sedentary behavior.

The studies that did describe mobile on-body sensing technologies tested the systems with
small sample sizes for usability and feasibility and did not include PA behavior change as a
main outcome.39,41,44,45,54 Future mobile technology use in this field should integrate
various components (SMS messaging, self-reported diaries, on-body sensors, real-time data
exchange, integrative technologies for incorporating sensor data, ecologic momentary
assessment, and geospatial data, for example) for adaptive and iterative interventions that
can provide personalized, real- or near-time feedback to users based on situational and
behavioral contexts.

The potential for integrated mHealth systems for PA and sedentary behavior measurement
and promotion is promising, but is in need of further research and development. mHealth
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research does not yet provide the evidence base to indicate how fully integrated mobile
systems that incorporate sensing capabilities and real-time or near-time data transmission
can be utilized to influence PA behavior and sedentary behavior change. Additionally, the
lack of pervasive use of personalization and real-time feedback in mHealth studies creates
difficulty in determining how these components can be most successfully used in mHealth
interventions to influence behavior change.

Further, the lag time between the fast pace of technology development and the slow pace of
research funding and designs such as the RCT needs to be closed by developing and
implementing innovative funding scaffolding and research designs that promote rapid
turnaround. Adaptive experimental designs such as the Multiphase Optimization Strategy
(MOST) and the Sequential Multiple Assignment Randomized Trial (SMART) could
provide study design and evaluation methods that are suited to the iterative development and
evaluation of mHealth interventions.65 Utilization of innovative study design could improve
understanding of the mobile technologies that are most effective for PA and sedentary
behavior measurement and interventions.
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Limitations
There are limitations to this review, some of which are inherent to the nascent field of
mHealth. For instance, there is a lack of consensus on the types of PA targeted and the
implementation of mobile technologies. It is therefore difficult to compare studies or to
derive a definitive understanding of best practices in mobile technology implementation
for behavior change.

Additionally, most studies were conducted over short periods of time. The lack of
longitudinal examination in the reviewed studies also renders it impossible to determine
whether these technologies are feasible for long-term PA behavior change maintenance in
free-living settings. Moreover, most of the studies reviewed focus only on PA and not on

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sedentary behavior. Decreased sedentary behavior is categorically different from increased

PA, as these two activity patterns are not necessarily reciprocal.66,67 Research has shown
that too much sedentary behavior, even when one achieves recommended PA, has adverse
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health consequences.7 There is increasing evidence that sedentary behavior should be

targeted for health interventions, so this is an outcome that requires attention in future
mHealth research.1

Conclusion
The objectives of this literature review were to determine how mobile technologies have
been used for PA and sedentary behavior detection and PA promotion, whether these
technologies have been harnessed for their potential to provide real-time feedback in
adaptive behavioral interventions, and whether mobile technologies have been successfully
utilized to change PA and sedentary behavior. This review found that the mobile
technologies utilized to develop mHealth PA and sedentary behavior assessment and
promotion systems have included: mobile phone-based journals and questionnaires, SMS
correspondence for self-monitoring of PA or communication about activities, and on-body
activity sensing systems for PA detection and promotion. Several studies have shown that
mobile PA journals and questionnaires are effective tools for measuring self-reported PA.
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Additionally, there is a lack of evidence of the efficacy of on-body mobile sensing systems
for accurate PA measurement. Several studies have demonstrated that use of SMS-based and
mobile journalbased interventions can positively affect PA and sedentary behavior.
However, these technologies have been predominantly utilized in isolation. mHealth
systems that integrate mobile technologies to provide real-time feedback, user-and health-
provider-in-the-loop, personalized, and adaptive interventions need to be developed and
tested for efficacy in order to take full advantage of mobile and connected capabilities.

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

Acknowledgments
The authors thank Ariel Hart for her assistance in the preliminary phases of this literature review. Funding for this
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study was received from NCMHD (supplement to P60 MD002254-01).

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Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version at, http://
dx.doi.org/10.1016/j.amepre.2013.05.012.

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Figure 1.
Flow diagram of selection process of articles for inclusion in the review
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